Reader, when this writer was a child, the baby brother — don’t call him that! — would, when exasperated, despatch offending elder siblings with a perfectly sounded-out “N-O means no.” Arms akimbo, brow furrowed, pitch declaring level of seriousness, the matter closed before it had properly opened. Credit to the parents for their kindergarten choices, wah! There was no appeal, no counter-offer, no graceful retreat into ambiguity, just total clarity, the end.

In the last two months, no has been on the lips of a few African capitals’ mouths, in response to American 30-60-90 hardball in a brave new transactional global health world. Whether all these nos are in every case a complete sentence, or just the opening gambit, remains to be seen. What is clear is that the word has lately been wielded with an attention-getting just so.

Harare went first. In late February, Zimbabwe withdrew from talks over a $367m bilateral health memorandum with the United States, calling the terms “lopsided.” Lusaka followed within days, suspending a deal worth more than $1bn after officials concluded that several clauses, including one apparently hitching health funding to a mining partnership, did not align with the national interest. Then a few days ago, Accra. Ghana walked away from a $109m, five-year package, citing concerns over the sharing of sensitive citizen health data. Three governments in three different rooms, with three rather different price tags on the table, arrived at the same single-syllable conclusion. Meanwhile, Kenya’s $1.6bn agreement moved forward after the Court of Appeal lifted orders that had temporarily blocked implementation of the medical cooperation framework with the United States.

How is all this to be read? As a robust, if multifaceted, defence of Common African Position on Pandemic Prevention, Preparedness, and Response (CAP-PPPR) in the face of Divide and Conquer, Season 55?

Washington’s “America First Global Health Strategy,” unveiled last year, replaced traditional aid with bilateral compacts requiring co-financing, performance tracking and, in several cases, the long-term sharing of pathogen and population health data and reach-in around them, to say nothing of mineral rights, transport corridors, and whatever else might reasonably be slipped into a schedule.

When Zimbabwe’s information minister explained Harare’s refusal, he framed the issue not as money but as multilateralism: a bilateral pathogen-sharing deal, he argued, would undermine the very system Africa has spent years championing in Geneva. Zambia’s objections centred on the entanglement of health aid with mineral access, while Ghana’s turned on data sovereignty and the absence of any guaranteed access to innovations derived from its citizens’ biological information. The particulars vary, perhaps decidedly. But the ricochet heard around the world from these three capitals was unmistakable: Africans can indeed say no. I’d rather starve than sign that.

The “rather starve” is not, alas, entirely figurative. The 2025 dismantling of USAID and the abrupt suspension of American health assistance has, by one tracker’s count, already contributed to hundreds of thousands of avoidable deaths. The Center for Global Development reckons the new compacts represent, on average, a 49% drop from 2024 funding levels, with recipient governments expected to absorb the gap within five years. The numbers describe a wager, not a posture.

What is being wagered, and why now? Perhaps the brazenness of this latest round has caused at least these three capitals to reflect on how far ceded health sovereignty had quietly exposed them, and to take the painful decision to lance the boil. If so, it is the right thing to do. But because they failed to consult their publics in advance, the choice is exceedingly painful, and the pain will be borne by people who were never asked whether they were willing to bear it. To refuse a billion dollars when your HIV programme depends on it is not a flourish. It is a calculation that the alternative, yes on these terms, is worse than the cliff. Whether the citizens whose treatment will be interrupted agree with that calculation is a question their governments have not yet thought to ask.

The edge of the cliff is looming, against the backdrop of the final stretch of negotiations on the Pathogen Access and Benefit-Sharing annex, the PABS annex, the last and most contested piece of the WHO Pandemic Agreement adopted at last year’s World Health Assembly. Negotiators reconvened in Geneva this week, but with member states unable to bridge key divides, discussions on the annex have now been extended to May 2027. The gap between blocs remains wide enough to swallow the original deadline whole. Positions have barely shifted, low- and middle-income countries continue to press for mandatory benefit-sharing, including guaranteed access to vaccines, therapeutics and diagnostics in exchange for the rapid sharing of pathogen data, wealthier countries press for safeguards on pharmaceutical innovation and open access to genetic sequences. The Pandemic Agreement itself cannot enter into force until the annex is finished, which gives every bilateral signature a quiet but forceful relevance as a thumb on the multilateral scale.

In a few weeks, African and other capitals, and the health diplomats who speak for them, will have to go home and explain the consequences of these negotiations to their publics. Whatever emerges from Geneva, and whatever has been signed or refused bilaterally, will land on the desks of finance ministers, in the wards of public hospitals, in the queues at primary health care facilities where the supply of antiretrovirals has dried up. This is what we got. This is what it cost. This is what we could not protect.

It causes one to reflect that engaging those publics beforehand, explaining the trade-offs, naming the red lines, soliciting a mandate rather than presenting a fait accompli, would make the coming medicine go down rather better. Sovereignty asserted on a citizen’s behalf, without the citizen, is a thinner thing than sovereignty asserted with one.  And perhaps, it also presents an opportunity to extend that need to be treated as mature adults to their own citizens. There is scarcely a country on the continent where the memory of having died to defend the principles of dignity and the right to self-determination is more than a grandparent’s generation away.

The capitals that have refused these bilateral deals have, broadly, framed the refusal as a defence of national interest, but whether their citizens recognise it as such when the consequences arrive in the form of stockouts, shuttered programmes, sickness, and death will depend almost entirely on whether the conversation happened in time.

That conversation will also determine the larger thing. The question hanging over Geneva, and over every capital weighing a bilateral against a multilateral commitment, is whether what is being defended is worth the price of defending it. A PABS annex that collapses, or one stripped of meaningful benefit-sharing, would arguably represent the last and best chance of operationalising equity in pandemic response squandered. A multilateral framework that holds, by contrast, would vindicate a decade of African diplomatic insistence that the rules of global health be written with rather than for the global majority.

Whether the diplomats now at work are negotiating a Pyrrhic victory in the form of a principled refusal that costs more lives than it saves, a multilateralism preserved on paper while its constituencies are abandoned in practice, or, conversely, delivering a lethal blow to multilateralism itself by signing away its premise in side-deals, will not be known on the day the Assembly votes. It will be known later, in the explaining. And the explaining, like the negotiation, is best done with a mandate already in hand.

To what are we saying no?